Dr. Mean Chhi Vun, director of Cambodia’s National Center for HIV/AIDS, Dermatology and STDs (NCHADS), offered an exciting progress report to the TB/HIV Working Group of the Stop TB Partnership at their meeting last week in Beijing, including representatives from tuberculosis (TB) and HIV programs in China and elsewhere in the Pacific region.
To give a quick epidemiological summary, Cambodia is a country of 14 million people that is designated as one of the 22 TB high burden countries in the world with an HIV prevalence of 0.8 percent. Sixty-four percent of the total population has been infected with tuberculosis. There are 52,180 persons eligible for antiretroviral therapy (ART) and as of June 2011 – ART coverage was 92 percent of individuals with CD4 counts <350. HIV prevalence has declined among TB patients in recent years from 11.8 percent in 2003 to 6.1 percent in 2009.
In 1999, the Cambodian Ministry of Health (MOH) created a TB/HIV committee and in 2002, the MOH endorsed a TB/HIV framework. In 2003, the country kicked off pilot projects implementing TB screening and isoniazid preventive therapy (IPT) at clinical sites providing ART and care for opportunistic infections. In 2006, they commenced HIV testing among TB patients.
Chhi Vun noted that TB intensified case finding (ICF) and IPT coverage has moved slowly because of the challenges of screening and diagnosing TB in HIV-infected individuals. Providers also worry that IPT will cause isoniazid resistance. Chhi Vun characterized the ultimate goal as making screening and diagnosis for TB “simple, feasible, accurate and low cost.”
An important catalyst for action in Cambodia was a study conducted by Dr. Kevin Cain and other Centers for Disease Control and Prevention (CDC) colleagues in Thailand, Cambodia and Vietnam. “After we learned from a global and regional evidence base, we moved quickly to implement three I’s – intensified case finding, isoniazid preventive therapy and infection control.” The MOH developed an operational plan in April 2010 and the TB and HIV departments moved to implement the program immediately. The HIV and TB departments developed a joint agreement, laying out clear responsibilities for each program.
Cambodia was successful in moving from pilots to widespread implementation and the country is getting results. HIV testing coverage among TB suspects increased from 32 percent in 2008 to 74 percent in 2010. In June 2010, the MOH implemented the 3 “I”s in eight pre-ART and ART sites and expanded to 28 sites by March 2011. Today, the program has been implemented in 35 ART sites. In 2009, there were only 44 HIV patients on IPT. In the first quarter of 2011 alone, more than 600 patients were placed on IPT. TB symptom screening among persons living with HIV was more than 86 percent in the first quarter.
“Now we have a ‘Five I’ program,” said Mean Chhi Vun, referencing recent important clinical trial results, including the Cambodian Early versus Late Introduction of Antiretroviral Drugs (CAMELIA) trial, which showed clear benefits to early initiation of ART for reduced morbidity and mortality for co-infected patients. Now Cambodia’s policy is to initiate ART in co-infected patients after two weeks of TB treatment, the fourth “I.”
The fifth “I” is integration, as in service integration. The MOH is already working to integrate TB, HIV and reproductive health services and civil society representatives from all of these areas sit at the planning table. According to Chhi Vun, the “community plays a critical role in supporting integration.” The goal is to ensure universal access to HIV, TB, sexually transmitted infection treatment and reproductive health services by 2015. They hope to integrate malaria services beginning next year as well.
There are of course challenges. These activities have increased the workload of health care workers. Follow-up with patients after TB screening and HIV testing to ensure that they access ART and TB treatment remains inadequate. Chhi Vun lamented that resources to finance transportation costs for patients were inadequate, and there is limited access to rapid TB diagnosis. Cambodia has 10 GeneXpert machines in the country so far. Important next steps highlighted by the energetic Chhi Vun included expanding IPT to 45 adult sites, introducing IPT in four pediatric AIDS care sites, and strengthening referral and follow-up linkages within and between TB and HIV community-based organizations. Last but not least, the MOH will work to improve monitoring and evaluation.